Provider Demographics
NPI:1578643276
Name:ROUTE 22 MEDICAL PC
Entity type:Organization
Organization Name:ROUTE 22 MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:LUIGIA
Authorized Official - Middle Name:GINA
Authorized Official - Last Name:NOTARISTEFANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:845-278-8797
Mailing Address - Street 1:1591 ROUTE 22
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:NY
Mailing Address - Zip Code:10509
Mailing Address - Country:US
Mailing Address - Phone:845-278-8797
Mailing Address - Fax:845-278-8798
Practice Address - Street 1:1591 ROUTE 22
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:NY
Practice Address - Zip Code:10509-4026
Practice Address - Country:US
Practice Address - Phone:845-278-8797
Practice Address - Fax:845-278-8798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203453207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02222755Medicaid
NY02222755Medicaid
G39320Medicare UPIN